Revision total hip arthroplasty - Home Study Program

AORN Journal,  Sept, 2002  by Cynthia Drake,  Marcia Ace,  Gerhard E. Maale

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The article "Revision total hip arthroplasty" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 3 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Sept 30, 2005.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on revision total hip arthroplasty (THA), the nurse will be able to

(1) describe the normal anatomy of the hip,

(2) identify the normal physiology of the hip,

(3) describe how hip pathophysiology results in the need for revision THA,

(4) explain how a ballistic chiseling system is used with hip implants during a revision THA procedure,

(5) discuss the preoperative phase for a patient undergoing revision THA,

(6) explain the steps of the revision THA procedure, and

(7) describe the postoperative course of a patient recovering from a revision THA.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Total hip joint replacement surgery enables hundreds of thousands of people to live full, active lives. (1) Using metal alloys and high-grade plastics and polymeric materials, orthopedic surgeons replace painful, dysfunctional joints with highly functional, long-lasting prostheses. During the past 50 years, many advances in design, construction, and implantation of artificial hip joints have been made, resulting in a high percentage of successful long-term outcomes.

Hip replacement procedures are highly successful in relieving pain and restoring movement. (2) Ongoing problems with wear and particulate debris exist and eventually may necessitate additional surgery, including replacing the prosthesis. The chance of a hip replacement lasting 20 years is approximately 80%, although, men and patients who weigh more than 165 lbs have higher rates of failure. In 2000, 309,000 total hip arthroplasty (THA) procedures were performed in the United States. An estimated 32,000 revision THAs also were performed the same year, of which approximately 45% required cement removal. (3)

Revision THA represents a challenge even for the most experienced surgeon. (4) A multitude of problems have to be considered for each presenting patient, including loss of bone stock, joint instability, infection, fracture, trochanteric nonunion, and difficulty in implant or cement removal. Most orthopedic surgeons recognize that revision THA is considerably more difficult and time consuming and that it carries greater liability for the surgeon than performing the primary THA. Although revision THAs are almost double the cost of primary THAs, the procedure has proved extremely cost effective when measured against medical treatment options. The main goal of the revision THA procedure is to restore the patient's hip function by repairing the biomechanical kinetics. In revision THA, compromised bone and soft-tissue injury may jeopardize long-term results of the revision. The use of any revision component must optimize the use of remaining bone after the primary hardware is removed. Removal of noncemented prostheses and cement removal for cemented implants now can be facilitated with a pneumatically powered ballistic chiseling system.

ANATOMY

The hip consists of the two coxal bones. (5) Each coxal bone forms with the fusion of three bones. The superior ilium fuses with the inferior and anterior pubis and also with the inferior and posterior ischium. The superior border of the ilium is the iliac crest, which ends in the anterior superior iliac spine. The pubis carries the symphysis pubis, which is a joint connecting the right and left coxal bones. The acetabulum is a deep fossa on the lateral side of each coxal bone where the ilium, pubis, and ischium come together.

The femur is the largest bone in the body. On its proximal end, the rounded head of the femur articulates with the coxal bone in the acetabulum. The head narrows distally into the neck. Lateral to the neck is a major bony projection called the greater trochanter. The lesser trochanter is medial and inferior. The trochanter serves as a site for muscle attachments.

The hip is a synovial, ball-and-socket joint formed by the head of the femur and acetabulum of the coxal bone. (6) The acetabulum fits tightly around the head of the femur so that unlike the shoulder, the hip sacrifices some movement for additional stability. The hip allows movement in all three planes of motion, including flexion-extension, abduction-adduction, and medial-to-lateral rotation. Abduction is movement of the leg away from midline and is limited by the greater trochanter contacting the outer ridge of the acetabulum. Adduction is movement of the leg toward the midline. Medial rotation is inward rotation along a vertical axis. Lateral rotation is outward rotation along a vertical axis and is a more extensive movement for the hip than medial rotation.